CMS Pub. 100-22, ch. 1, § 30

A participating individual eligible professional or group practice (see §20 above) who

satisfactorily reports data on Physician Quality Reporting System quality measures as described

in §70 may earn an incentive payment equal to the applicable quality percent of the Secretary’s

estimate of allowed part B charges for covered professional services furnished by the eligible

professional or group practice during a specified reporting period (see §40 below).

For 2007 and 2008, the applicable quality percent is 1.5% incentive.

For 2009, the applicable quality percent is 2.0%.

For 2010, the applicable quality percent is 2.0%.

For 2011, the applicable quality percent is 1.0%.

For 2012 through 2014, the applicable quality percent is 0.5%.

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In addition, from 2011 through 2014, eligible professionals who are physicians may qualify to

earn an additional Maintenance of Certification Program incentive (the applicable quality percent

for each year is 0.5%). To earn this additional incentive payment, each year, a physician must:

• Satisfactorily submit data on quality measures (i.e. meet the criteria for satisfactory

reporting to earn a Physician Quality Reporting System reporting incentive) for the 12-month reporting that applies for the year;

• Have such data submitted on their behalf through a Maintenance of Certification

Program that meets the criteria for registry (as specified by CMS) or an alternative form

and manner determined appropriate by the Secretary;

• Participate in a Maintenance of Certification Program more frequently than is required to

qualify for or maintain board certification status; and

• Successfully complete a qualified Maintenance of Certification Program practice

assessment more frequently than is required to qualify for or maintain Board certification

status.

For each year, the Physician Quality Reporting System incentive payment is calculated based on

an eligible professional’s a group practice’s total estimated Medicare Part B PFS allowed

charges for all covered professional services: (1) furnished during the applicable reporting

period, (2) received into the CMS National Claims History (NCH) file by no later than 2 months

after the end of the reporting period, and (3) paid under or based upon the Medicare PFS.

Because claims processing times may vary by time of the year and Medicare Carrier/AB MAC,

participating eligible professionals or group practices should submit claims from the end of a

reporting period promptly, so that if, for example, the reporting period ends on December 31st of

a particular year, claims from the end of the reporting period will reach the NCH file by February

28th of the following year. Physician Quality Reporting System incentive payments are paid as a

lump sum. Physician Quality Reporting System incentive payments are generally made in the

middle of the year following the year in which the reporting period falls. There is no beneficiary

co-payment or notice to the beneficiary regarding the Physician Quality Reporting System

incentive payments.

The Physician Quality Reporting System incentive payment amount is calculated using estimated

allowed charges for all covered professional services under the Medicare Part B PFS, not just

those charges associated with reported quality measures. The term “allowed charges” refers to

total charges. Note that the amounts billed above the Medicare Part B PFS amounts for assigned

and non-assigned claims do not apply to the incentive payment. The statute defines Physician

Quality Reporting System covered professional services as those paid under or based upon the

Medicare Part B PFS only, which includes technical components of diagnostic services and

anesthesia services, as anesthesia services are considered fee schedule services though based on a

different methodology.

Other Part B services and items that may be billed by eligible professionals but are not paid

under or based upon the Medicare PFS do not apply to the Physician Quality Reporting System

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incentive payment. In addition, any amounts owed to CMS, such as from overpayments or other

withholds, are subtracted from the incentive payment amount.

The analysis of satisfactory reporting is performed at the individual eligible professional level

using individual-level NPI data, and beginning in 2010, for group practices participating in the

GPRO, the group practice level using TIN data. For both participating individual eligible

professionals and group practices, CMS uses the TIN as the billing unit. Therefore, any

Physician Quality Reporting System incentive payments earned are paid to the TIN holder of

record. For individual eligible professional, Physician Quality Reporting System incentive

payments are paid to the holder of the TIN, aggregating individual incentive payments for groups

that bill under one TIN. For eligible professionals who submit claims under multiple TINs, CMS

groups claims by TIN for payment purposes. As a result, a provider with multiple TINs who

qualifies for the Physician Quality Reporting System incentive payment under more than one

TIN would receive a separate Physician Quality Reporting System incentive payment associated

with each TIN.

In situations where eligible professionals are employees or contractors who have assigned their

payments to their employers or facilities, section 1848(m)(1)(A) of the Act specifies that any

Physician Quality Reporting System incentive payment earned be paid to the employers or

facilities.